Senior Checkup Form – Feline"*" indicates required fieldsDate* MM slash DD slash YYYY Patient's Name* Patient's Name Circle the appropriate response:* Male Female Male Neutered Female SpayedBreed*Color*Date of Birth or Approx. Age*Owner's Name* First Last Owner's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork PhoneCell Phone*Email NUTRITION/DIET INFORMATIONWhat brand does your pet eat? Dry, canned or moist?Please describe any snacks, supplements, or table food your pet receives & how often.Who feeds the pet?How many times a day does your pet eat?How is your pet’s appetite?Have you noticed any changes in your pets eating habits or appetite recently?EnvironmentHow often does your pet go outside?Where does your pet sleep?Are there other pets in the family? If so, how many & what kind(s)?Are there any young children in the family?EXERCISEWhat kind of exercise or playtime does your pet get and how often?Please describe any problems with this exercise. Does your pet have trouble jumping?Have you noticed any limping, stiffness, or pain when your pet first gets up? Does he/she improve after awhile?Does your pet tire easily?Any increase or decrease in activity?Does your pet cough, pant, or have trouble breathing? Any changes in breathing pattern?WEIGHTHow do you monitor your pet’s weight? (Scale, visually, other?)Have you noticed any recent weight loss or gain?DENTAL CAREHas your pet ever had its teeth cleaned? If so, when was the last time?How often does your pet have professional cleanings?Do you ever brush your pet’s teeth?Does your pet ever seem to have trouble chewing? Bad breath? Drooling?BEHAVIORHave you noticed any changes in your pet’s behavior (examples: less enthusiastic greeting, less interaction with family, hiding)? If so, please describe.Please list any behavioral problemsHave you recently felt your pet was (please check all appropriate answers):* More anxious/nervous More sensitive to pain More lethargic Moody Less tolerant None of the aboveWhen did you notice changes?Does your pet vocalize more?SPECIAL SENSESHave you noticed any changes in your pet’s vision? Do your pet’s eyes look different?Does your pet run into objects or become anxious in an unfamiliar environment? Does your pet ever act lost in a familiar environment?Have you noticed any changes in your pet’s hearing?OTHER INFORMATIONHow much water does your pet drink in a day?Does your pet prefer drinking from running water?Any recent changes in amount of water your pet drinks or frequency of drinking?Any changes in amount of urine in the litter box or frequency of urination?Does your pet ever miss the litter box? If so, where? Is it urine or stool?Any changes in amount or frequency of your pet’s bowel movements? Constipation?Any problems with skin or hair coat? Changes in grooming habits?Any coughing, sneezing, discharge from nose or eyes, scratching or shaking head?Any lumps or bumps?Any past medical problems of which we are not aware?Does your pet vomit hair? Any increase in frequency?What medications are your pet taking currently? *Studies show that as many as 17% of middle to older age cats that appear healthy upon physical examination have an underlying disease. 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